New Customer Registration Form

Dealer Application
Name*

First NameLast Name
Business Name*
# of Locations
Address*

Street Address

Street Address Line 2 (optional)

City (optional)State / Province (optional)

Postal / Zip Code
E-mail*
Phone Number*
What is your business type?*

Aquarium storeAquarium service companyPet storeOnline retailerCustom aquarium builderOther
If Other, please specify:
Years in Business*
# of Locations
Approximate Annual Revenue
# of Employees
Tank Showroom Square Footage

About how many tanks in the following gallon sizes do you sell a year?

	< 50g	50-100g	100-200g	200-300g	300g+
# of tanks

What brands do you carry for tanks over 100 gallons?
Do you offer installation/maintenance services?*

YesNo
How did you hear about us?*
Business Registration Upload*

Cancelof
Valid ID Upload*

Cancelof
If you have any questions about our products, dealership, logistics or anything else, contact us at info@aquavim.com or 917-363-8851
Should be Empty:

Dealer Application